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Thank you for participating in The Academy’s survey on uninsured and underinsured populations. Please answer as many questions as you are able and return the survey to The Academy via fax, email, clicking ‘Submit’ at the end of the form.

If you have any questions or comments, please contact The Academy. Thanks in advance for your responses!

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1.What is your self-pay payer mix? Please list.

2010

2011

5.What is the aging of your current self-pay accounts receivable?

% of billed self-pay A/R over 90 days

% of billed self-pay over 120 days

% of billed self-pay over 180 days

Does this include only pure self-pay or both pure and residual self-pay after insurance? Please check one.

6.What types of financial assistance or payment options does your hospital/organization offer?

7.Does your hospital/organization utilize automation in its process to determine patients’ eligibility for Medicaid, charity care, and other financial assistance programs (SSI disability, etc.)?

Yes

No

8.Based on provisions set forth by federal health reform, does your organization seek to identify patients less than 26 years of age or with pre-existing conditions to connect them with external funding options?

Yes

No

9.Does your hospital/organization utilize any of its charity care dollars to pay for physician/primary care visits for uninsured individuals in order to avoid the high costs that can be incurred if preventive care is not received?

Yes

No

10.Does your hospital/organization typically provide scheduled patients with an estimate of their out-of-pocket charges?

Yes

No

11.Do you provide a single statement to patients that includes both hospital and physician fees for related services within your organization?

Yes

No

12.Do you provide estimates of out-of-pocket costs to patients seen and discharged from the emergency department?

Yes

No

13.If ED patients are identified to be non-emergent through a Medical Screening Exam, what are the next steps taken? Please check all that apply.

Provide treatment regardless

Require down payment to proceed with treatment

Provide patients with list of alternative care settings in the area

Personally schedule patients for primary care-type appointments near their residence

Other

14.How many financial counselors does your hospital/organization currently have? Please list.

Counselors reporting to Patient Access

Counselors reporting to Patient Financial Services

Counselors reporting to other departments

15.Do you have dedicated financial counselors in the emergency department?

Yes

No

If you answered ‘Yes’, how many?

If you answered ‘Yes’, what hours are they present in the ED?

16.Please provide the following productivity benchmarks for financial counseling staff.

Number of accounts touched each day

Number of individuals seen/discussions held each day

Please list any other productivity metrics you utilize for financial counselors.

17.When do you first outsource your self-pay collections?

18.What is the contingency fee rate charged by your self-pay collection agency/agencies? Please list.

Early-out

Primary agency

Secondary agency

19.What is your organization’s net recovery rate (recoveries less contingency fees) from your self-pay collection agency/agencies? Please list.